SPAMEDiCA
Infinite Vitality Clinic
FOTOFACIAL and SonoPeel or Microdermabrasion TREATMENT
INFORMED CONSENT BOOKLET
INSTRUCTIONS
This is an informed-consent document that has been prepared by Dr. Mulholland and the SpaMedica
Aestheticians and Laser Nurses to help inform you about Microdermabrasion, WrinkleLIGHT and
Fotofacial treatments, their risks, benefits and alternatives. During your consultation, we will review with
you the potential benefits of the treatments, the alternatives and the few risks that are associated. You may
ask any questions about the procedures and we will provide you with answers to these questions to the best
of our ability. It is important that you read the information contained in this booklet carefully and
completely. Only when you have no questions or concerns do you initial each page, indicating that you
have read and fully understood all the items it discusses. When you arrive at the end of the booklet, please
sign the consent for the procedure. If you have any remaining questions about the alternatives, proposed
benefits or risks involved with Microdermabrasion, WrinkleLIGHT or Fotofacial treatments, do not initial
or sign the consent without speaking with the aesthetician or laser nurse during consultation or by calling 1(800)-561-3376 and leaving a message.
INTRODUCTION
Microdermabrasion, Lasers and Intense Pulsed Light (IPL) have been used effectively and safely to treat a
variety of cosmetic skin problems. Over the past few years, extensive clinical research has been conducted
using microdermabrasion, lasers and IPL in the treatment of unwanted wrinkles, textural irregularities and
skin blemishes.
Microdermabrasion, or a CRYSTAL PEEL, employs tiny aluminum oxide crystals passed across the skin
to remove the outer, “dead layer “ of skin called the Stratum Lucidum. By sequentially removing this outer
skin layer over several treatments, textural irregularities, pore size, acne scars and pigmentation blemishes
can be smoothened, softened, faded and improved. The microdermabrasion process generally enhances the
overall health and vitality of your skin.
Microdermabrasion is often performed in conjunction with WrinkleLIGHT and Fotofacial treatments.
During WrinkleLIGHT and Fotofacial treatments pulsed light and laser light is directed at the skin. The
light passes through the outer surface of the skin, called the epidermis and penetrates into the undercarpet
of the skin known as the dermis. Once in the dermis, the pulsed light and laser energy stimulates a cell
called a Fibroblast to produce your own new collagen. Over several treatments, this new collagen
smoothens and softens the appearance of your wrinkles, pore size and textural irregularities. Using special
filters to control the wavelength of pulsed light, sun-damaged skin with pigmentation abnormalities,
vascular blemishes, such as spider veins and rosacea can be lightened and improved.
While delivering the pulsed light and laser energy to the skin, it is important to cool that skin to avoid
injury. Cooling gel is one method of protecting the skin during WrinkeLIGHT and Fotofacial treatments.
Microdermabrasion, WrinkleLIGHT and Fotofacial treatments are simple office procedures performed by a
physician trained aesthetician and/or laser nurse and requires no needles, medications or surgery. You will
be assessed by an aesthetician where your goals and expectations for Microdermabrasion, WrinkleLIGHT
and/or Fotofacial treatment will be discussed. During the consultation your skin type and facial cosmetic
concerns will be assessed and discussed. The estimated duration and cost of each session or series of
sessions will be provided and you may, if you are found to be a candidate, proceed to treatment at the time
of this initial visit.
Microdermabrasion, WrinkeLIGHT and Fotofacial therapy may require between 4-6 treatments to achieve
maximum optimal aesthetic skin rejuvenation in each area. During your screening consultation, you will
read this booklet to help you decide if Microdermabrasion, WrinkleLIGHT and/or Fotofacial treatments are
the right procedures for you.
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Following Microdermabrasion, WrinkeLIGHT and/or Fotofacial treatments, there may be a minor degree
of redness and puffiness to the skin, with some tingling discomfort that usually disappears in 1-2 hours.
You may apply makeup immediately and return to work or regular activities. It is very rare for patients to
develop bruising over the treated skin and, if this occurs, it is usually mild and fades away over 8-10 days.
Although there is no special skin care regime necessary between treatments, it is highly recommended you
begin a comprehensive home skin care program to optimize and maintain the cosmetic improvements you
obtain with your Microdermabrasion, WrinkleLIGHT and Fotofacial therapy.
Microdermabrasion, WrinkleLIGHT and Fotofacial treatments are new, proven, high-tech skin care
procedures. SpaMedica was one of the first centers in Canada with this technology and the aestheticians
and laser nurses are very experienced. Published studies indicate that Microdermabrasion, WrinkleLIGHT
and Fotofacial treatments can improve the appearance of wrinkles, pore size, textural irregularities and
vascular and pigmentation blemishes in over 80% of cases, with patients reporting a noticeable
improvement in the cosmetic appearance of their skin during and at the completion of their program.
The best candidates for Microdermabrasion, WrinkleLIGHT and Fotofacial therapies should not be tanned
at the time of treatment. That means, allow your tan to fade (for about 6 weeks) before treatment and avoid
tanning for 3-4 weeks after as the pigment will absorb some of the pulsed light or laser energy and may
cause a skin reaction. If you are using artificial tanning creams, allow these to fade (for 2-3 weeks) prior to
beginning treatment.
SpaMedica is one of Canada’s most sophisticated, full service cosmetic surgery and laser skin care center.
We have treated thousands of skin care, laser hair removal, laser leg vein and cosmetic surgery patients.
SpaMedica is one of the country’s most experienced Skin care and Laser centers. Although our large
experience has proven these treatments to be very safe, there are some uncommon risks that you must
consider before proceeding with treatment. You should balance these rare risks with proven benefits of less
discolored and blemished-reduced skin.
BENEFITS OF MICRODERMABRASION, WrinkleLIGHT and FOTOFACIALTREATMENTS
The most obvious potential benefits are an improvement in the appearance of wrinkles, pore size, textural
irregularities, acne scarring, vascular and pigmentation blemishes of aging or sundamaged skin.
ALTERNATIVES
The easiest and safest alternative is to leave your cosmetic skin concerns alone and camouflage them with
make-up. Laser resurfacing, chemical peels, injectable collagen, hyaluronic acid, fat or artecoll and
cosmetic surgery are all alternative therapies to Microdermabrasion, WrinkleLIGHT and/or Fotofacial
treatments. However, each of these alternative treatments will require some recovery time until you are
socially presentable, whereas with Microdermabrasion, WrinkleLIGHT and Fotofacial treatments you have
no recovery time and can return to work immediately.
RISKS OF MICRODERMABRASION, WrinkleLIGHT AND FOTOFACIAL TREATMENTS
Every cosmetic skin procedure involves a very small degree of risk and, although exceedingly uncommon,
it is important you understand and accept the rare risks involved with Microdermabrasion, WrinkleLIGHT
and Fotofacial treatments. An individual’s informed decision to undergo any cosmetic procedure is based
upon a comparison of the risks to potential benefits, alternatives and costs. Although the vast majority of
Microdermabrasion, WrinkleLIGHT and Fotofacial patients do not ever experience any of these
complications, you will have discussed each of them with our aesthetician and/or laser nurse to ensure you
fully understand the alternatives, risks, potential complications and average outcomes of these procedures.
Discomfort - Microdermabrasion is a very comfortable procedure and most patients find the treatment to
be a very pleasing and relaxing experience. WrinkleLIGHT and Fotofacial treatments are very well
tolerated office treatments. With these treatments you may experience a minor and tolerable degree of
burning and/or tingling discomfort with each laser or pulsed light treatment.
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Skin Wound - It is exceedingly rare for Microdermabrasion, WrinkleLIGHT or Fotofacial treatments to
cause a blister or skin wound. This is more of a risk in darker skin types. If a blister or skin wound develops
it may take 5-10 days to heal, and, in extremely rare instances, may leave a noticeable whitening or
darkening of the skin or, even more rarely, a scar.
Scarring - Occurs less than 0.1%. If your are unlucky enough to develop a wound and a scar, the scar may
end up being flat and white (hypotrophic), large and red (hypertrophic) or even be large and extend beyond
the margins of the injury (keloid). Subsequent treatment or surgery may be required to improve the
appearance of the scar.
Pigment Change - Microdermabrasion should not cause a pigment change in your skin. You may undergo
Microdermabrasion when your skin is tanned. With pulsed light and laser therapies used in WrinkleLIGHT
and Fotofacial treatments, there is a small risk of <1% of temporary hyperpigmentation (increased pigment
or brown discoloration) or hypopigmentation (whitening of the skin). Usually these pigment effects are
temporary and resolve over several weeks or months. Permanent hyperpigmentation or hypopigmentation is
very rare and may occur in less than 1 % of cases. It is essential that you not tan your skin, or use tanning
creams, prior to treatment as this will increase your risk of a pigment change or skin wound. You should
not have WrinkeLIGHT or Fotofacial treatments if you have tanned skin until the tan has faded appreciably
(at least 6 weeks). Ask your aesthetician to give you hydroquinone or a Retin-A cream prescription to
hasten the fading of your tan so you may proceed to treatment.
Bruising - It is exceedingly uncommon to have any skin bruising following treatment. If bruising occurs, it
can be camouflaged immediately and will usually resolve in 8-10 days. As the bruising fades, there may be
a rust-brown discoloration of the skin (hyperpigmentation) that may take special creams to fade away.
Infection - Because Microdermabrasion, WrinkleLIGHT and Fotofacial treatments involve no actual
cutting, surgery or skin penetration, infection is exceedingly rare.
Excessive Redness and Swelling - Rarely, a minor degree of redness and/or puffiness of the skin may
follow treatment and usually lasts 1-2 hours and is easily camouflaged with make-up. This may persist, in
rare instances, for 1-2 days. A mild steroid cream (0.5% hydrocortisone available at the clinic) will usually
settle this.
Fragile Skin - The skin overlying the treatment area may become quite fragile. Although uncommon, the
fragile skin can become reddened and the outer layer may peel off, much like a blister. This usually settles
in 8-10 days.
Additional Treatment - Your final result and maximum cosmetic facial enhancement will likely take 4
Microdemabrasion treatments and 6 Fotofacial treatments. Over time, with gravity, sun exposure, and
normal aging your wrinkles, large pores, textural abnormalities, vascular and pigment blemishes will
reappear. You may elect to treat again. In most instances, it is recommended that you have a maintenance
Microdermabrasion and WrinkleLIGHT and/or Fotofacial session every 3 months after completion of the
initial course, to maintain the facial enhancement and rejuvenation.
Lack of Satisfaction - No facial wrinkles, blemishes and skin types respond the same to
Microdermabrasion, WrinkleLIGHT and Fotofacial treatments. Your response may be subject to variation,
but on average, almost 100% of patients who have undergone treatment report a noticeable improvement of
between 40-70% in the appearance, quality and youthful vitality of their skin.
Pregnancy - Although no known adverse reactions upon a fetus are known to result from WrinkleLIGHT
and/or Fotofacial therapy , we do not recommend proceeding with treatment if you are known to be
pregnant.
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Health Insurance - Facial wrinkles, pores, textural irregularity, vascular and pigment blemishes are
cosmetic concerns and pose no medical or health care threat. Most health insurance companies, including
OHIP, exclude coverage for these treatments. Complications that may occur from Microdermabrasion,
WrinkleLIGHT and Fotofacial treatments may be considered a health care concern and are usually covered.
Additional Surgery/Treatment Necessary - There are many variable conditions in addition to risks and
potential complications that may influence the long-term result from Microdermabrasion, WrinkleLIGHT
and Fotofacial treatment. Even though risks and complications can occur infrequently, the risks cited in
this booklet are particular for Microdermabrasion, WrinkleLIGHT and Fotofacial treatment. Other
complications and risks can occur but are even more uncommon. Should complications occur, additional
surgery or treatment may be necessary. The practice of medicine and surgery is not an exact science.
Although good results are expected, there is not a guarantee or warranty expressed or implied as to the
results that may be obtained. Infrequently, it is necessary to perform additional treatment to improve your
results.
Financial Responsibilities - Depending on whether the cost of treatment is covered by an insurance plan,
you will be responsible for necessary payments. Additional costs may occur should complications develop
from treatment. There are no refunds once a treatment has been performed.
Disclaimer - Informed consent documents are used to communicate information about the proposed
treatment of a condition along with disclosure of risk and alternative treatment(s). The informed consent
process attempts to define principles of risk disclosure that should generally meet the needs of most
patients in most cases.
What the Aesthetician or Laser Nurse has discussed with you and included again in this booklet are the
material risks both common and uncommon. The physician feels a reasonable person would want to know,
understand, and consider these risks in trying to decide if Microdermabrasion, WrinkleLIGHT and
Fotofacial treatments are something with which they would like to proceed.
However, informed consent documents should not be considered all inclusive in defining other methods of
care and risk encountered. Your Aesthetician or Laser Nurse may provide you with additional or different
information that is based on all the facts in your particular case and the state of medical knowledge.
Informed consent documents are not intended to define or serve as the standard of medical care. Standards
of medical care are determined on the basis of the facts involved in an individual case and are subject to
change as scientific knowledge and technology advance and as practice patterns evolve.
It is important that you read the above information contained on this and all preceding pages
carefully and have all of your questions answered before signing the consent on the next page.
Questions and concerns can be answered during consultation or by contacting the office at 1-(800)561-3376 and leaving a message for the aesthetician or laser nurse, who will return your call as soon
as possible.
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CONSENT FOR PROCEDURE AND/OR TREATMENT
I have received the following information/informed consent booklet for:
1.
I hereby authorize Dr. Mulholland and/or such assistants as may be selected to
perform the following procedure and/or treatment:
__________________________________________________________________
________________________
2.
I recognize that during the course of the procedure/treatment unforeseen
conditions may necessitate different procedures than those above. I therefore
authorize the above physician and/or assistants or designees to perform such other
procedures that are in the exercise of his or her professional judgment necessary
and desirable. The authority granted under this paragraph shall include all
conditions that require treatment and are not known to my physician at the time
the procedure is begun.
3.
I consent to the administration of such anaesthesia considered necessary or
advisable. I understand that all forms of anaesthesia involves risk and the
possibility of complications, injury and sometimes death.
4.
As part of the requirements of the Canadian Association for Accreditation of
Ambulatory Surgical Facilities, my chart may be subject to a peer review for
quality control.
5.
I acknowledge that no guarantee has been given by anyone as to the results that
may be obtained.
6.
I consent to the photographing of appropriate portions of my body, for medical,
scientific, or educational purposes, provided my identity is not revealed by them.
7.
For purposes of advancing medical education, I consent to the admittance of
observers to the treatment room.
8.
I understand that the signature of the witness (if a non-physician) on this
document indicates only that the signing of my name has been observed and not
that the witness has necessarily provided information regarding the procedure.
9.
IT HAS BEEN EXPLAINED TO ME BY MY PHYSICIAN AND/OR
ASSISTANTS IN A WAY THAT I UNDERSTAND:
THE ABOVE TREATMENT OR PROCEDURE TO BE UNDERTAKEN
THERE MAY BE ALTERNATIVE PROCEDURES OR METHODS OF
TREATMENT
THERE ARE RISKS TO THE PROCEDURE/TREATMENT PROPOSED
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Infinite Vitality Clinic
ANY QUESTIONS I MAY HAVE ASKED HAVE BEEN ANSWERED TO MY
SATISFACTION
I CONSENT TO THE TREATMENT OR PROCEDURE AND THE ABOVE LISTED
ITEMS (1-9).
I AM SATISFIED WITH THE EXPLANATION.
Patient or Person Authorized to Sign for Patient
_________________________________________
_______________________________________
DATE
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Please Print Name Here
WITNESS
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